| NPI | 1144717505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 316392) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 5101025274) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-20 |
| Last Update Date | 2025-02-08 |